School academic climate and oral health (tooth loss) in adolescents

contextual level through a proxy variable–i.e., the school’s participation in the ENEM—and not evaluated at the individual level. Admittedly, educational aspirations are determined by other factors besides school educational climate, such as perceived parental support for educa- tion [42], which could affect the aspirations at the individual level. Hence it is a limitation of the current study that we did not directly measure educational aspiration in each participant, nor did we take account of other variables that might influence educational aspiration indi- rectly. That said, measuring and controlling for individual educational aspiration could amount to statistical over-adjustment. The point is analogous to debates about whether to con- trol for individual SES when examining the contextual influence of neighborhood socioeco- nomic disadvantage on individual health outcomes. On the one hand, individual SES is a compositional confounder (prior common cause) of neighborhood poverty and individual health. At the same time, individual SES potentially lies on the pathway between neighborhood SES and individual health (because neighborhood poverty constrains individual access to edu- cational opportunities and labor markets). The point is a very subtle one, often overlooked in multi-level studies. Our conclusion is that school academic climate–over and above individual/school socioeco- nomic disadvantage–is correlated with oral health status. Our proposed mechanism of action is that a strong academic climate increases individual motivation for oral health maintenance

behaviors. The reason is because a stronger academic climate sends a signal to the student that scholastic success is valued, and that excellence will be rewarded in the future by prospects of stable employment. In other words, a strong academic climate reduces uncertainty about the future, and improves the students’ capacity to plan for the future. Our argument is that when students grow and learn within a context of less uncertainty about their future, they will develop not only stronger motivation to study, but that there will be spillover benefits in other aspects of behavior–in this instance, preventive oral health maintenance behaviors. Our findings have an important implication since tooth loss has a cumulative effect with deleterious consequences for current and future general health. A policy implication of our study is that focusing on the educational opportunities of adolescents may be a means of pro- moting the health of disadvantaged populations. Supporting information S1 Dataset. (DTA) Author Contributions Conceptualization: Carolina da Franca Bandeira Ferreira Santos, Ichiro Kawachi. Data curation: Carolina da Franca Bandeira Ferreira Santos. Formal analysis: Carolina da Franca Bandeira Ferreira Santos. Project administration: Carolina da Franca Bandeira Ferreira Santos, Fabiana Godoy, Valde- nice Aparecida Menezes, Viviane Colares. Writing – original draft: Carolina da Franca Bandeira Ferreira Santos. Writing – review & editing: Patrı´cia Maria Zarzar, Raquel Conceic¸ão Ferreira, Ichiro Kawachi. PLOS ONE School academic climate and tooth loss in adolescents

PLOS ONE | https://doi.org/10.1371/journal.pone.0233505 May 21, 2020 8 / 11